Barchester Healthcare
Other
Action Taken
Windmill Manor has created a new Agency Folder with key policies. Barchester is rolling out a modified induction checklist, pocket guide and poster across all homes by the end of February 2020, and compliance will be checked via the Quality Governance Framework. (AI summary)
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Dear Madam Coroner, Inquest touching the death of Iris Skinner Prevention of future death report - Windmill Manor Care Home, Oxted Surrey I write further to the conclusion of the inquest of Ms Iris Skinner held on 26-2 7 November 2019. Barchester Healthcare were granted Interested Party status in respect of these proceedings. I am in receipt of your Regulation 28 Report
— Action to Prevent Future Deaths dated 17 December 2019 and note the matter of concern is that agency staff employed by Windmill Manor Care Home in Oxted, and potentially more broadly across the Barchester Healthcare group, may be unfamiliar with the Barchester Healthcare Head Injury Policy. Please find the actions taken and planned in Windmill Manor and across Barchester homes in order to address this matter of concern. A copy of this information has also been supplied to the Care Quality Commission. At Windmill Manor the specific actions that have been taken include: A new Agency Folder is now in place in the home with printed copies of all the key policies, this includes Falls management, Head injury, Management of Medications, Choking, Tissue Viability, Bed Rail Assessment and Safeguarding of Vulnerable Adults. The file also contains the relevant contact details i.e. General Manager, Clinical Development Nurse, Regional Director, GP who would be available to provide advice and support should it be required. All agency nurses are then allocated time to review the information and are required to Barchester Healthcare Ltd Baicliestr I Iealthtire Ltd.3rd Floor, The Aspect, 12 hnsI)tIrv Sqtiare, London, EC2A lAS Tel: t)2f) 7382 28(()
• Fax: 02t) 7382 289()
• Email: info@barchester.com
• www.hurchester.com RetWied iii England Nn. 27922i15
BARCHESTER Ceriv fer sign that they have seen and read this as part of their induction prior to commencing their shift. I attach evidence of the documents which have been completed by the two agency staff who have been in the home since December 2019 and reviewed the file (pdf: Staff Signatures and pdf Agency Induction Record 01 and pdf Agency induction record LN).
• Notices have been put on each community staff notice board in relation to the new procedure for agency nurse induction and the General Manager has planned to speak to each individual nurse regarding the changes by 17th January 2020. 1 attach evidence that two Barchester Nurses have already been updated. (pdf: Staff signatures]
• The General Manager at Windmill Manor has also contacted the agency providers to inform them of the new processes in relation to the responsibilities of the agency staff accessing the available file which contains the key policies.
• The General Manager at Windmill Manor has also agreed to complete spot checks with agency nurses on duty to test their knowledge to ensure they have read and understood the policies.
• In addition all the Nurses’ stations in the home have been provided with an up to date copy of the Royal Marsden Handbook of Clinical Practice which provides guidance on management of clinical conditions including head injury and falls management. As a company, we have thoroughly reviewed our current procedures and processes in relation to lessons learnt in this case and are also making some changes to our processes.
• Our Policies are currently located on our internal intranet site and accessible through our home computers and via the Learning and Development training tablets in each home. Homes may print off the policies for staff, however there is a risk that the most recent policy may not be the one in use at that time as they are regularly updated in line with new practices and external body recommendations such as NICE/NMC/CQC. The policies are all version controlled and the Barchester Ilealtheare Ltd l3archistt’r i1calEh(a1c Ltd. 3rd Floor. Th Asiwct. 12 Fifl,l)tIrv St1wtn. London. EC2A lAS Tel: 1)20 7382 286() Fax: t)2() 7382 2801)
• Email: ink)tu:1)archcster.com vww.barchetcrrom Rtttid in England Nn. 27922H5
BARCHESTER organisation is informed via our electronic weekly communication ‘iBarchester’ of any changes or updates to any policy to minimise the risk of homes using an old policy.
• As part of our Quality Governance Framework Barchester Healthcare has a ‘Policy on policies’ which identifies the process, formulation and format of all our organisational polices. At the beginning of each policy there are ‘Key policy points listed’ which summarise and identify for quick reference the key messages and practices in each of the policies.
• The Director of Nursing, as the policy owner, is currently identifying 10 key policies in which the Head injury and Falls policy will be included, and will condense the key points into a pocket guide for all agency staff.
• The pocket guide will have an FAQ section and also space to complete the details of who the agency nurse can contact whilst on duty for advice during their shift; this may be another nurse on duty in the home, the General Manager or the person in charge that has handed over to the agency staff member in the previous shift.
• To supplement the pocket guide, in the home staff room there will be a wall mounted commercially produced poster which contains very similar information as the pocket guide and will provide a reference point for all staff in the home in relation to key policy information.
• The timeframe for completing the printing and introduction across all the Barchester homes for the modified induction checklist, pocket guide and poster is the end of February 2020. We would be pleased to send a copy of the pocket guide format to you once the pocket guide has been produced.
• Currently all Agency workers in a Barchester home complete an agency worker induction prior to working in the home and the new pocket guide development will be added to the agency worker induction check list once it has been produced and in use.
• To monitor compliance against the new agency induction checklist which will include distribution of the pocket guides and signatures on Barchester Ilealthcare Ltd Harchc’stci’ It( Llthcir’ Ltd. 3rd Fiuui. The Aspect. 12 Fiiishurv Scjtwt’c, London, EC2A lAS tel: ()2() 7382 286() Fax: t)2() 7382 28)() Email: infotharcIwster.coni
• www.haiclwstei.com Rcgiskiecl in IngIand No. 2Q22i5
BAPCHESTER IeJrat, tVe the induction checklist this will be checked by the Regional Directors and Audit programme across Barchester homes as part of the overarching Quality Governance Framework. It is hoped that following receipt of this correspondence and the enclosed documentation, you may be reassured that Barchester Healthcare has taken significant steps to address the matter of concern you identified. I hope this provides you with the information needed to consider this matter. Should you require any further information, please do not hesitate to contact me.
— Action to Prevent Future Deaths dated 17 December 2019 and note the matter of concern is that agency staff employed by Windmill Manor Care Home in Oxted, and potentially more broadly across the Barchester Healthcare group, may be unfamiliar with the Barchester Healthcare Head Injury Policy. Please find the actions taken and planned in Windmill Manor and across Barchester homes in order to address this matter of concern. A copy of this information has also been supplied to the Care Quality Commission. At Windmill Manor the specific actions that have been taken include: A new Agency Folder is now in place in the home with printed copies of all the key policies, this includes Falls management, Head injury, Management of Medications, Choking, Tissue Viability, Bed Rail Assessment and Safeguarding of Vulnerable Adults. The file also contains the relevant contact details i.e. General Manager, Clinical Development Nurse, Regional Director, GP who would be available to provide advice and support should it be required. All agency nurses are then allocated time to review the information and are required to Barchester Healthcare Ltd Baicliestr I Iealthtire Ltd.3rd Floor, The Aspect, 12 hnsI)tIrv Sqtiare, London, EC2A lAS Tel: t)2f) 7382 28(()
• Fax: 02t) 7382 289()
• Email: info@barchester.com
• www.hurchester.com RetWied iii England Nn. 27922i15
BARCHESTER Ceriv fer sign that they have seen and read this as part of their induction prior to commencing their shift. I attach evidence of the documents which have been completed by the two agency staff who have been in the home since December 2019 and reviewed the file (pdf: Staff Signatures and pdf Agency Induction Record 01 and pdf Agency induction record LN).
• Notices have been put on each community staff notice board in relation to the new procedure for agency nurse induction and the General Manager has planned to speak to each individual nurse regarding the changes by 17th January 2020. 1 attach evidence that two Barchester Nurses have already been updated. (pdf: Staff signatures]
• The General Manager at Windmill Manor has also contacted the agency providers to inform them of the new processes in relation to the responsibilities of the agency staff accessing the available file which contains the key policies.
• The General Manager at Windmill Manor has also agreed to complete spot checks with agency nurses on duty to test their knowledge to ensure they have read and understood the policies.
• In addition all the Nurses’ stations in the home have been provided with an up to date copy of the Royal Marsden Handbook of Clinical Practice which provides guidance on management of clinical conditions including head injury and falls management. As a company, we have thoroughly reviewed our current procedures and processes in relation to lessons learnt in this case and are also making some changes to our processes.
• Our Policies are currently located on our internal intranet site and accessible through our home computers and via the Learning and Development training tablets in each home. Homes may print off the policies for staff, however there is a risk that the most recent policy may not be the one in use at that time as they are regularly updated in line with new practices and external body recommendations such as NICE/NMC/CQC. The policies are all version controlled and the Barchester Ilealtheare Ltd l3archistt’r i1calEh(a1c Ltd. 3rd Floor. Th Asiwct. 12 Fifl,l)tIrv St1wtn. London. EC2A lAS Tel: 1)20 7382 286() Fax: t)2() 7382 2801)
• Email: ink)tu:1)archcster.com vww.barchetcrrom Rtttid in England Nn. 27922H5
BARCHESTER organisation is informed via our electronic weekly communication ‘iBarchester’ of any changes or updates to any policy to minimise the risk of homes using an old policy.
• As part of our Quality Governance Framework Barchester Healthcare has a ‘Policy on policies’ which identifies the process, formulation and format of all our organisational polices. At the beginning of each policy there are ‘Key policy points listed’ which summarise and identify for quick reference the key messages and practices in each of the policies.
• The Director of Nursing, as the policy owner, is currently identifying 10 key policies in which the Head injury and Falls policy will be included, and will condense the key points into a pocket guide for all agency staff.
• The pocket guide will have an FAQ section and also space to complete the details of who the agency nurse can contact whilst on duty for advice during their shift; this may be another nurse on duty in the home, the General Manager or the person in charge that has handed over to the agency staff member in the previous shift.
• To supplement the pocket guide, in the home staff room there will be a wall mounted commercially produced poster which contains very similar information as the pocket guide and will provide a reference point for all staff in the home in relation to key policy information.
• The timeframe for completing the printing and introduction across all the Barchester homes for the modified induction checklist, pocket guide and poster is the end of February 2020. We would be pleased to send a copy of the pocket guide format to you once the pocket guide has been produced.
• Currently all Agency workers in a Barchester home complete an agency worker induction prior to working in the home and the new pocket guide development will be added to the agency worker induction check list once it has been produced and in use.
• To monitor compliance against the new agency induction checklist which will include distribution of the pocket guides and signatures on Barchester Ilealthcare Ltd Harchc’stci’ It( Llthcir’ Ltd. 3rd Fiuui. The Aspect. 12 Fiiishurv Scjtwt’c, London, EC2A lAS tel: ()2() 7382 286() Fax: t)2() 7382 28)() Email: infotharcIwster.coni
• www.haiclwstei.com Rcgiskiecl in IngIand No. 2Q22i5
BAPCHESTER IeJrat, tVe the induction checklist this will be checked by the Regional Directors and Audit programme across Barchester homes as part of the overarching Quality Governance Framework. It is hoped that following receipt of this correspondence and the enclosed documentation, you may be reassured that Barchester Healthcare has taken significant steps to address the matter of concern you identified. I hope this provides you with the information needed to consider this matter. Should you require any further information, please do not hesitate to contact me.